In today’s world, logging more than 20 years with the same health system is no easy feat. But what’s even more impressive is when a CIO has spent his entire career with the same organization and played an integral role in its growth, particularly from an IT standpoint. Twenty years after being asked to build a network at DuBois Regional, Tom Johnson is guiding the organization through a major evolution that has included acquiring community hospitals and achieving a successful big-bang implementation of Cerner. In this interview, Johnson talks about the challenges in working with owned physician practices, the paradigm shift that is needed to get patients more involved in their care, how he spends most of his time, and what he’s doing to avoid being pigeon-hold as a technology guy.
Chapter 3
- The problem with HIEs
- Industry trends — “I think you’re going to see a lot of continued acquisition and rip and replace of systems”
- Thoughts on telemedicine
- “Most of my time is spent on regulatory compliance”
- Having a full plate with MU, RAC audits, eRx
- “Integration is the only way to survive”
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Bold Statements
What good is dumping millions of dollars in precious man hours into building HIEs when you’re not even going to need them? How many small hospitals and independent physician offices do you think there are going to be in the next two years? I would argue almost zero. Who are you going to be exchanging with?
If UPMC acquires a smaller hospital, do you think they maintain the EMRs? No. They rip them out and they put in whatever they have. So I think you’re going to see a lot of continued acquisition and rip and replace of systems.
For it to really take off, the payers have to say, ‘this is important to us. We’re going to fund this. This is the new model, and we’re going to incentivize you to do this.’ Until that happens, I think there’s still going to be a limit of access to care for certain patient populations.
Most of my time is spent on regulatory compliance, so I don’t have a lot of luxury to say, ‘this is something I want to work on,’ or ‘this is a good strategic item for our organization.’
Integration is really the cornerstone of everything we do. With everything we do, we say, ‘okay, we’re going to comply with Meaningful Use, but how do we make sure it’s an integrated solution?’ That’s how I build my mission, my vision, my strategy, and my capital budget.
Gamble: It’s interesting; in speaking to CIOs, I find that more seem to be focused on getting the exchange going in their own organization and their own backyard. Let’s figure this out before we even worry about the state level, because that’s what’s more important right now.
Johnson: The state that I’m in has not done a good job with statewide HIE. The only criticism I have of that is the fact that it’s a huge state. One side is completely different than the other, and there may be hundreds of different EMRs. How do you connect all that together and do it on whatever budget they have? It’s incredibly difficult work. So even though I’m critical of them, at the same time I can understand why it’s been difficult to get any real success, because it’s almost impossible to get some of these huge health systems to all come to the table and say, ‘yes, I’m going to work with you.’
Honestly, when you look at all the consolidation that’s happening between EMR vendors and providers of care, we may only have a few health systems left in the state over the next two to three years. You might have two huge health systems — one on the left and one on the right. So at the end of the day, what good is dumping millions and millions of dollars in precious man hours into building HIEs when you’re not even going to need them? How many small hospitals and independent physician offices do you think there are going to be in the next two years? I would argue almost zero. Who are you going to be exchanging with?
Gamble: Yeah, exactly. It’s going by the wayside, we’re certainly seeing that. You have UPMC right there. You have Geisinger in the central part of the state.
Johnson: Yes.
Gamble: You’ve got those two giants right there.
Johnson: If you look at the EMR side of it, how many people — how many big health systems aren’t buying Epic or Cerner? So what’s left? It’s going to be big health systems on Epic or Cerner, and then you have maybe some mid-sized hospitals that are left still on Cerner. I would argue just about everyone else is going to be gone. And when these hospitals acquire another hospital — like if a UPMC acquires a smaller hospital, do you think they maintain the EMRs? No. They rip them out and they put in whatever they have. So I think you’re going to see a lot of continued acquisition and rip and replace of systems that goes hand in hand with the acquisitions. I think the natural evolution is going to be that there are only a few big players left. There’s going to be a few EMRs that are out there and the other one percent of systems is going to slowly disappear.
Gamble: It does seem like things are headed in that direction.
Johnson: It does.
Gamble: The community hospitals are so rare, especially where I live in New Jersey. There are so few of them.
Johnson: Oh yeah, that’s an interesting market as well, but it’s the same thing playing out there as it is here in Pennsylvania. Once you have a huge health system, the government can say, ‘here you go, take care of all these Medicare and Medicaid patients. We’ll pay you so much money per month per patient, and then you take care of it.’ And they’ll be positioned to do that, and patients are going to be incentivized financially either with a payment or a penalty to influence these behaviors. ‘Don’t come to the hospital. Call this number.’ ‘Don’t come in to the ED. We’ll get someone out to see you.’
Because they don’t want them coming in anymore. It will be a completely different model. People are going to be complaining and saying, ‘I can never get into the hospital. Every time I call, they say don’t come in,’ which is completely different. Now everyone wants you to come in. You call now and say, ‘I have an earache. I need you to write a script for me.’ Oh no. It’s, ‘you need to come into the office. I need to see you,’ which is why all these little urgent care centers have all popped up, because people don’t want to go in to see the doctor a week from now. They want to just run in, get the medicine, and get out of there as fast as possible.
Gamble: Yeah, minute clinics and things along those lines. Do you have those out where you are?
Johnson: Yes, we do. We have a few of our own that we put in Wal-Mart, and we just got our first competitive one that came in called MedExpress, which just opened last week.
Gamble: Is it fairly a rural area where you are?
Johnson: Yes.
Gamble: Okay, so obviously you have patients who are located pretty far from a care provider.
Johnson: Absolutely. We have a 15-county reach because we’re two hours northeast of Pittsburgh and two hours southeast of Erie, so we’re kind of in a geographic no man’s land with just a lot of small little communities spread out over the middle of the state. So that’s why we have a 15-county reach, because there’s just a small community with 1,000 people and there’s another one with 2,000 people. We have 9,000 people that all come to us as the closest place to go. If we can’t treat them because it’s too acute or complex, then we can life-flight to Pittsburgh or we can life-flight to trauma centers that are an hour or two hours away.
Gamble: With that kind of a patient population, is telehealth or telemedicine a priority?
Johnson: It really hasn’t been, and it’s probably more because of the alignment of payments. We do some telehealth. For example, we have a wheelchair clinic that we do with telehealth with UPMC where they have experts in wheelchair design and management. When someone’s getting a wheelchair, we’ll get them on the video and they’ll help and say, ‘Raise this up. Adjust this to get them set appropriately for the patients.’
We also have a very small behavioral telehealth operation we do with some of the northern tier facilities, but it really hasn’t taken off beyond that, only because I can spend $30,000 in equipment, and then I’ll get a $10 reimbursement for the telehealth visit. If you think of setting up all the telecommunications lines, which have recurring cost to them, and all the hassles in getting all the equipment set up, training the doctors, training the remote site, having staff there, and staff here, and patients are not really crazy about it — you do all that, and all you’re going to get is an extra $10.
Gamble: It’s hardly worth it, right?
Johnson: Yeah, there’s not a huge motivator to do it. I think for it to really take off, the payers have to say, ‘this is important to us. We’re going to fund this. This is the new model, and we’re going to incentivize you to do this.’ Until that happens, I think there’s still going to be a limit of access to care for certain patient populations. It’s just not going to go anywhere, because unfortunately for us we operate either at a breakeven or at a negative on our operations just because of how we’re reimbursed.
We’re in the low 70s for government reimbursement, just because of the socioeconomic status of this region. So we can’t just say we’re going to be leading this area and we’re going to dump tons of money into it, hoping sometime in the future the payers go this direction. We, unfortunately, can’t do that. So we have to wait until they say, ‘now we’re going to do this’ for us to respond.
Gamble: I think a lot of people are in that position now.
Johnson: Yeah, I agree.
Gamble: So in terms of what’s on your plate, are there any big projects you’re focusing on in the near future? I’m sure stage 2 is up there.
Johnson: Unfortunately, most of my time is spent on regulatory compliance, so I don’t have a lot of luxury to say, ‘this is something I want to work on,’ or ‘this is a good strategic item for our organization.’ If you look at Meaningful Use, at ICD-10, at all the different standardization and codification of data that needs done to comply with those items, and you look at RAC audits and other payer audits, e-prescribing penalties, PRQS, and all these different regulatory items. We have Joint Commission. We have the Department of Health. It’s almost non-stop regulatory where you don’t have the luxury to work on anything other than that.
What I do is try to focus and weave integration into everything we do. Integration is really the cornerstone of everything we do. Do not let anyone buy a disparate system or a siloed system that isn’t part of our core, because that’s what we can’t support. With everything we do, we say, ‘okay, we’re going to comply with Meaningful Use, but how do we make sure it’s an integrated solution?’ That’s how I build my mission, my vision, my strategy, and my capital budget. At any of my meetings, I make sure that the cornerstone of everything we do is a mindset of integration — getting everyone on the same page because that’s the only way we’re going to survive a little bit longer.
I’m not saying ultimately we can sustain ourselves as an independent organization or health system. I know inevitability it will eventually catch up with us and say, ‘our model no longer works. We’re going to have to completely change it.’ But until that day happens, we have to integrate to improve patient safety, to improve quality, and ultimately lower our cost, because we’re all on the same page.
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